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FOR IGE use <br /> f (For Non-Transferable, Revocable, Suspendable)� -;ra PUMP&WELL <br /> y ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> mit thework herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtforaper <br /> j made in compliance with San Joaquin County Ordi ance No. 1862 and t e rules and regLul-0ions of the San Joaquin Local Health District. <br /> sL : dk fI rCdCity/Town —flJ4�i <br /> Exact Site Address ,. :� <br /> Owner's Name Phone g Q <br /> City _ �- <br /> I Address � a t✓� <br /> Contractor's Name /YGa�3Y1 �' Licen s e# Q2'13? Business Phone -�ys`�� 3 <br /> Contractor's Address <br /> �_ Emergency Phone =� 1 <br /> ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): ? NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT ) <br /> DISTANCE TO NEAREST: Septic Tansewer Lines Pit Privy <br /> Tank <br /> Sewage Disposal Field kCesspool/Seepage Pit Other <br /> I <br /> Pri operty Line Private Domestic Well Public Domestic Well <br /> INTENDED USE °i TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing ,ayC <br /> DOMESTIC/PRIVATE ji � - <br /> ❑ DOMESTIC/PUBLIC �❑1 DRIVEN Gauge of Casing — <br /> ❑ IRRIGATION ,�, lam+ GRAVEL PACK Depth of Grout Seal <br /> I ,d <br /> ❑ CATHODIC PROTECTION 4At ROTARY Type of Grout <br /> ❑ DISPOSAL .. ❑ OTHER Other Information _ . D `J 1)2,okk 2 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -/ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ! ❑ State Work Done <br /> PUMP REPAIR: ll .�. -� _ <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: a Well Diameter ,Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify thatTl have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> � . <br /> Home owner.or, liceri`sed agent's signature ceriN:les the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such mannbr as to become subject to workman's compensation laws of California." <br /> Contractor's'h ring or sub-contracting signature certifies the following."I certify that in the performan a of thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout inspection prior to grouting and a final in ectfon ' <br /> . <br /> • � _�"�" -, ..Date: <br /> F Signed X <br /> (Draw Plot Plan on Reverse Side) _ xi <br /> O DEP TMENT US ONLY <br /> PHASE I <br /> Date <br /> Application Accepted.By <br /> -'4 <br /> Additional Comments: _ <br /> ase II Grout inspection /RPh Final Inspection <br /> Inspection By Date Inspection By%�' +, '' Date / A <br /> (/�{' PER UNIT R I ❑ EACH uary 1 &Received 13y January 31 ❑ July 1 &Receive3`"Iy July 31 <br /> Fee Is Due: ❑ ANNUALL7' . I. REMIT <br /> BASE EXPLANATION BILLI REMITTANCE AMOUNT DUE *�!+rf.KED <br /> - n <br /> TE DATE REMITTED ''AMOUNT <br /> v <br /> FEE <br /> LESS <br /> I PRORATION ,la <br /> PLUS 00 wr7 <br /> PENALTY <br /> OTHER r <br /> OTHER 1 <br /> Received.by •Date Receipt.No Permit No. Issuance Date Mailed 'Delivered <br /> APPLICANT—RETURN ALLyCOP1E5 TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ter. <br />